Endometriosis and the Colorectal Surgeon

1. Endometriosis and the Colorectal Surgeon NA Scott

2. Endometriosis and the Colorectal Surgeon • Aetiology and Incidence • Diagnosis and Investigation • Management – endometriosis and pain • Radical surgery for stage IV disease (Rectovaginal disease)

3. Endometriosis and the Colorectal Surgeon • 10% of all women – 6% presenting for sterilisation, 21% of those presenting for infertility treatment • Retrograde menstruation – peritoneal endometriosis • Coelomic metaplasia (?rectovaginal septum) • Vascular dissemination; surgical implantation Aetiology and Incidence

4. Endometriosis and the Colorectal Surgeon • Secondary dysmenorrhoea • Deep dyspareunia • Pelvic (rectal) pain • Infertility • Pelvic mass Diagnosis and Investigation

5. Endometriosis and the Colorectal Surgeon Diagnosis and Laparoscopy • laparoscopy is gold standard • 0.06% bowel perforation in diagnostic procedure • 1.3% bowel perforation in operative laparoscopy Harkki-Siren P, Sjoberg J, Kurki T. Major complications of laparoscopy: a follow-up Finnish study. Obstet Gynecol 1999; 94:94-8. .

6. Endometriosis and the Colorectal Surgeon Diagnosis and Laparoscopy • Minimal (Stage I) • Mild (Stage II) • Moderate (Stage III) • Severe (Stage IV)

7. Endometriosis and the Colorectal Surgeon Diagnosis and Cyclical Rectal Bleeding • based on case reports – rectal and sigmoid endometriosis associated with “cyclical” bleeding • endometriosis is in seromuscular layer not mucosa • ? Disruption of mucosa – not menstruation into bowel Forsgren H, Lindhagen J, Melander S, Wagermark J. Colorectal endometriosis. Acta Chir Scand. 1983;149(4):431-5

8. Endometriosis and the Colorectal Surgeon Management • age • fertility plans • previous treatment • nature and severity of symptoms • location and severity of disease Women with endometriosis-associated infertility and pain may have to decide which is the major priority as there is no evidence that hormonal therapy alone improves fertility

9. Endometriosis and the Colorectal Surgeon Endometriosis and pain – medical management • complementary medicines, analgesics, NSAIDs • hormonal therapy (combined OC, progestogens, danazol, GnRH agonists)

10. Endometriosis and the Colorectal Surgeon Endometriosis and pain – hormonal therapy • induce atrophy in ectopic endometrial tissue • equally effective in producing symptom relief • significant side effects - poor long term compliance • do not affect biological mechanisms responsible for disease • recurrence – 37% minimal disease; 74% severe disease Clinical Green Top Guidelines The Investigation and Management of Endometriosis (24) - Jul 2000 http://www.rcog.org.uk/guideline

11. Endometriosis and the Colorectal Surgeon Endometriosis and pain – surgical therapy Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994; 62:696-700.

12. Endometriosis and the Colorectal Surgeon Endometriosis and pain – Stage IV disease Radical surgery means doing a hysterectomy with removal of both ovaries and is reserved for women with very severe symptoms, who have not responded to medical treatment or conservative operations

13. Why involve a Colorectal Surgeon in radical surgery for pelvic endometriosis ?

14. Endometriosis and the Colorectal Surgeon Stage IV disease – rectovaginal endometriosis “……embryonic remnants in the recto-vaginal septum undergoing metaplastic change to “endometrial-like” tissue, and by proliferation become surrounded by hyperplastic smooth muscle, representing a typical “adenomyotic nodule” deep in the recto-vaginal septum “

15. Endometriosis and the Colorectal Surgeon Stage IV disease – rectovaginal endometriosis

16. Endometriosis and the Colorectal Surgeon Stage IV disease – rectovaginal endometriosis

17. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis - preoperative • MDT discussion of the indications and likely extent of pelvic surgery • Preoperative counselling of patient and family as to the indications and extent of surgery, including the risk of stoma formation, autonomic pelvic nerve injury and bladder dysfunction, ureteric injury and pelvic haemorrhage • Bowel preparation and stoma siting

18. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis - intraoperative • Lloyd Davies position • Midline incision • Ureteric stents

19. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis - intraoperative • round ligaments and ovarian pedicles divided • uterine artery divided to release the ureters • separate rectum to complete the hysterectomy by reaching the normal rectovaginal plane below the endometriosis

20. Endometriosis and the Colorectal Surgeon Stage IV disease – rectovaginal endometriosis

21. Endometriosis and the Colorectal Surgeon

22. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis – en bloc anterior resection • uterus mobilised, bladder separated from anterior vaginal wall • rectum mobilised laterally and posteriorly • approach and enter the rectovaginal plane from the sides below the endometriosis

23. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis – en bloc anterior resection • approach and enter the rectovaginal plane from the sides below the endometriosis

24. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis – en bloc anterior resection • is lateral pelvic side wall involved • how far down does the process extend ?

25. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis – en bloc anterior resection • successive division of anterior and posterior vaginal walls • staple across the rectum • remove specimen en bloc

26. Endometriosis and the Colorectal Surgeon Rectovaginal endometriosis – en bloc anterior resection • stapled anastomosis • loop stoma • OUTCOMES

27. Jolyon Forda, James Englisha*, William A. Milesb, Theo Giannopoulosa Pain, quality of life and complications following the radical resection of rectovaginal endometriosis BJOG: An International Journal of Obstetrics & Gynaecology 2003;111:353 • 48 shaving of the pre-rectal fascia, • 2 had a disc resection of the rectum, • 10 had an anterior rectal resection • median follow up period was 12 months (range 2 to 22 months) • 86% (38/44) reported an improvement • 27 (61%) had a good response (pain completely gone or greatly improved). Radical resection is an effective treatment for rectovaginal endometriosis. Hysterectomy and rectal resection were associated with a better response and quality of life.

28. Urbach DR, Reedijk M, Richard CS, Lie KI, Ross TM. Bowel resection for intestinal endometriosis. Dis Colon Rectum. 1998 Sep;41(9):1158-64. • 1992- 1996 29 patients undergoing bowel resection for Stage IV endometriosis • 93 % low anterior resection • (Other – appendicectomy, terminal ileum resection, sigmoid resection) • mean follow up 22 months in 26 patients • 100% subjective improvement • 46% cured (resolution of symptoms without further medical or surgical therapy) • concomitant TAH, BSO and anterior resection (OR 12; 95% CI 1.8-81.70 Total abdominal hysterectomy and bilateral salpingo-oophorectomy at the time of bowel resection correlates with improved outcome

29. Endometriosis and the Colorectal Surgeon Summary • very common condition that is managed in large majority by gynaecological medical and laparoscopic ablative therapy (NB bowel perforation rate) • cyclical rectal bleeding is of interest only to exclude a sinister cause – it is rarely an indication for surgery (rectal pain in Stage IV disease is a much more relevant problem) • Stage IV pelvic surgery with rectovaginal involvement can be exceptionally difficult. Preoperative planning and counselling as to the risks and morbidity is essential • Rectovaginal endometriosis can be managed by sharp separation but a difficult low anterior resection must be planned for